All of us psychiatrists have exercised our responsibility for the involuntary admission of patients. Some patients (and many families) have expressed gratitude for this temporary but fundamental abrogation of civil freedoms – the freedom of movement – but for many patients it may be a source of fear and of loss of control and autonomy (even though the illnesses that they are experiencing also undermine control and autonomy). It may also reflect an upstream failure of less intrusive and earlier interventions to treat mental illness.

Involuntary admission: is there an alternative?

In an era of being patient-centred and recovery-focused, is a reduction in rates of involuntary hospitalization desirable? If you’re a human rights lawyer, the answer may be “well, yes, obviously”. If you’re a clinician, the answer may be “that depends on whether the patient ends up better or worse”. Nevertheless, there are a number of clinical initiatives in place whose goal would be to reduce the frequency of involuntary hospitalization (which does not preclude an increase in the rate of voluntary hospitalization).

So along comes a careful systematic review and meta-analysis of randomized trials to examine four categories of intervention that have, as their explicit primary or secondary outcome, a reduction in the rates of involuntary admission to psychiatric inpatient units. The interventions will seem familiar to any reader who has been involved in the care of people with severe and persistent mental illness. But the results are surprising.